Image-guided and Bronchoscopic Localization Techniques Used to Facilitate Minimally Invasive Pulmonary Metastasectomies

Pulmonary metastasectomy is associated with increased disease-free and overall survival in well-selected patients. Prerequisites to pulmonary metastasectomy include adequate pulmonary reserve and the ability to completely resect the identified metastasis. The likelihood that a patient will benefit from metastasectomy is driven by control of the primary tumor and other sites of disease, tumor biology and is dictated by tumor histology, presence of nodal metastasis, and number of metastases. Traditionally, open thoracostomy and bimanual palpation of the lung were used to identify pulmonary metastasis for resection. Increasingly video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) have been used in the performance of metastasectomy. These minimally invasive approaches reduce perioperative discomfort, length of stay, and may facilitate reintervention if new pulmonary metastasis develop. Given the reduced ability to palpate the lung using a minimally invasive approach, several techniques have been developed to facilitate intraoperative identification of pulmonary metastasis. These techniques fall into three broad categories: intraoperative imaging, image-guided labeling, and systemic targeting. This review provides an overview of the various risks, benefits, and effectiveness of these techniques. We also provide a brief review of the indications for minimally invasive metastasectomy. Finally, we perform a critical assessment of the associated literature with a focus on the current limitations and future directions of the field.